Account Setup – WeCare Pharmacy

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Practitioner Name(Required)

First Last

NPI Number(Required)

DEA Number(Required)

Practice Name(Required)

Medical Director

NPI Number

DEA Number

Practice Owner

Shipping Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Credit Card

CC Exp. Date

CVV

Email for shipping notifications(Required)

Phone(Required)

Fax

Username

Password

Enter Password Confirm Password